ANALYSIS OF THE 45 YEAR OLD FEMALE PATIENT
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45 year old female case
By G. Saahithya reddy
Roll no -141
The complete details of patient's history https://alekyatummala.blogspot.com/2020/09/45-yr-female-with-anasarca.html?m=1 is given in this link
Main complaints of the patient are :
1. Pedal edema pitting type
2. Generalised edema
3. Shortness of breath at rest (NYHA grade 4)
4. Chest pain on right side
5. Oliguria
1.Causes of generalised edema :
a. Heart failure
b. Hepatic cirrhosis
c. Edema of renal disease
d. Nephrotic syndrome and other hypoalbumenic states
e. Drug induced edema
f. Nutritional origin
Analysis :
1. The patient has :
- generalised edema - indicates fluid is getting escaped into third space loss which is leading to other symptoms such as dyspnea , abdominal distension , pedal edema
- hypertension : deranged function of RAAS mechanism can lead to hypertension and can cause renal failure or it can be vice versa
- anuria initially and oliguria after few days = due to vasconstriction theres no much blood circulation flowing to kidney which decreases gfr thereby decreasing urine output
- anemia ( hb = 6g/dl ) : which indicates theres loss of erythropoietin levels which is normally produced
- proteinuria = 2.8g/dl : it indicates proteinuria ( a normal kidney do not let proteins to excrete out )
- azotemia
- reduced serum albumin levels markedly
- metabolic acidosis = due to deranged acid - base regulation metbolic acidosis is caused
- all the above findings point towards the kidney disease
- hypokalemia , hyponatremia , hypocalcemia and hyperphosphatemia = deranged function of electrolytes which is maintined by kidneys
2. The patient's edema is associated with dyspnea grade 4 i. e sob at rest and the edema is extensive in legs which aggravate on walking
Lab findings : serum urea levels markedly raised, serum creatinine levels raised and sodium levels decreased
2d Echo : Findings are left ventricular hypertrophy
these findings could raise a suspicion of heart disease (it could be secondary to renal disorder )
what is the anatomical and etiological diagnosis of the patient :
- ANATOMICAL DIAGNOSIS - all the symptoms and lab findings point towards kidney diseases
- ETIOLOGICAL DIAGNOSIS - since the patient is type 2 diabetic , it could probably be DIABETIC NEPHROPATHY
what are the reasons for :
1.AZOTEMIA - a significantly reduced GFR can cause increase in plasma creatinine levels ,leading to retention of nitrogenous waste products such as urea (defined as azotemia )
azotemia may result from reduced renal perfusion , intrinsic renal disease or postrenal processes
2. ANEMIA - the kidney's function is to produce adequate amount of erythropoietin , when there is kidney damage these levels are reduced thereby causing anemia ( relative deficiency of erythropoeitin )
other causes include :
- diminished red blood cell survival
- iron deficiency due to loss of appetite and malnutrition
- folate or vitamin b12 deficiency
4. ACIDOSIS - normally kidneys maintains acid-base regulation , which when dsturbed due to any kidney disorder causes metabolic acidosis . in this patient ph = 7.19 and reduced bicarbonate levels of 6.7 mmol/l which indicates metabolic acidosis .it occurs because of :
- increase in endogenous production of acid (such as lactate or ketoacidosis )
- loss of bicarbonate levels
- accumulation of endogenous acids because of inappropriately low excretion of net acid by the kidney ( as in CKD )
what is the rationale of her treatment plan detailed day wise in record ?
On day 1 :
1.Inj . NaHCO3 is given inorder to neutralize the acidosis
EFFICACY -
treat acidosis with ventilation and perfusion by increasing plasma bicarbonate , buffers excess hydrogen ions and raises blood ph and reverses clinical manifestations caused by acidosis
also thought to worsen heart conditions and liver functions
As given in the above link
INDICATIONS OF IV SODIUM BICARBONATE :
- TO treat metabolic acidosis when the underlying disease is diarrhea , vomiting , or kidney related diseases
- high blood potassium
- tricyclic anti-depressant overdose
- cocaine toxicity
- contraindicated in patients who are losing chloride
- it should be used with great care in patients of CCF , severe CKD due to its sodium content because in these coditions sodium retention is a problem
- it should be given in patients using corticosteroids with caution
- as an antacid to treat heartburns , indigestion , upset stomach
- Hypersensitivity
- metabolic/respiratory alkalosis and hypocalcemia - because alkalosis produces tetany
3. ORAL HYPOGLYCEMIC AGENTS - used as diabetic agent to lower glucose levels in the blood
4. ANTI HYPERTENSIVES - to treat hypertension (to lower blood pressure value)
On day 2 :
1. Inj .HAI - used in type2 diabetes patients when their meat plan , weight loss , exercise and antidiabetic drugs do not achieve targeted blood sugar levels
2. tOROFER - for treatment of iron and folic acid deficiency i.e anemia
3.PAN -Treatment of conditions due to excess acid secretion in the digestive system
4. LASIX - a diuretic which is used to reduce risk of strokes , heart attacks and kidney problems
contraindications are :
- kidney disease
- hypokalemia
- diabetes - when taken furosemide it is hard to control blood sugar levels
- liver disease
On day 3
1.tab Dytor - given to control fluid overload and blood pressure since the patient had higher blood pressure on day 3
2.telma - Telmisartan is given to treat hypertension, heart failure and diabetic kidney disease .may be because of its limitation that it reduces the amount of urine and increases kidney damage it could be stopped
3. Nicardia is given to lower blood pressure
4.Orofer and erythropoietin inj- in order to correct anemia and increase levels of erythropoietin which further corrects anemia
5. Shelcal - it is given to treat hypocalcemia
6. Potchlor syrup - to correct hypokalemia
7.nodosis - it is an antacid, to neutralize the excess acid present in stomach
On day 4:
1.Lactulose - since the patient complained she had constipation she was given lactulose after which she passed the stools
2.inj.monocef- it is an antibiotic. Used to treat UTI, or any other infections
3. Protein x powder - given since the patient is malnourished
but excess use can cause coma, hepatic damage, metabolic disturbances, unpleasant taste in mouth
On day 5
The patient was further evaluated to improve her condition
what was the indication for dialysing her and what was the crucial factor that led to the decision to dialyze her on the 3rd day of admission ?
- severe breathlessness due to pulmonary edema
- acid-base problems ( METABOLIC ACIDOSIS )
- pericarditis
- electrolyte imbalance
On 3rd day of her admission the crucial factor that led to the decision to dialyze her was due to - FLUID OVERLOAD / PULMONARY EDEMA REFRACTORY TO DIURETICS and Refractory anuria
what are the other factors other than diabetes and hypertension that led to her current condition ?
I think it is because of anemia , diabetic ulcer and constipation
what are the expected outcomes in this patient ? Compare the outcomes of similar patients globally and share your summary with reference links ?
as mentioned in the above link :
chronic pressure overload , progressive volume overload , cardiomyopathy with the additional risk factor of Diabetes , Anemia could lead to preserved LVEF / reduced LVEF which further lead to the outcome of :
- Progression of CKD
- HF hospitalization
- Sudden arrhythmic death
- Pump failure death
How and when would you evaluate her further for cardio-renal HFpEF and what are the mechanisms of HFpEF in diabetic renal failure patients ?
Evaluation for HFpEF must be done on the day of admission itself if there is suspicion of heart related disorder such as heart failure as per the patient's symptoms ,clinical examination and laboratory diagnosis
Evaluation for cardio-renal HEpEF :
- Echocardiography - provides information on chamber volumes , ventricular systolic and diastolic dysfunction , wall thickness , valve function and filling pressures
- Chest radiography - to screen for other sources of dyspnea
- Electrocardiography - to detect rhythm disturbances or evidence of prior myocardial damage or pericardial disease
- MRI
- global longitudinal strain analysis
- whole -body bioimpedance technique
- extended cardiac rhythm monitoring
- Pulmonary artery ambulatory monitoring
- thoracic impedance monitoring
decreased renal blood flow leads to the stimulation of RAAS mechanism resulting in :
- sodium ,water retention leading to volume overload thereby increasing blood pressure and cardiac work , myocrdial fibrosis finally causing heart failure
- leads to vasoconstriction leading to increased afterload and increased blood pressure finally leading to heart failure https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6737277/
what is the utility of tools like CKD-AQ ?is telugu among the 68 languages in which it is translated ?
The CKD-AQ is a novel PRO measure that captures the frequency and severity of the most relevant symptoms and impacts associated with anemia . future studies will evaluate its psychometric properties and its potential utility in anemia management as quoted in the given link
yes telugu is one of the 68 languages in which it is translated .
what is the contribution of PEM to her severe hypoalbuminemia ? what is the utility of tools such as SGA( subjective global assessment ) in the evaluation of malnutrition in CRF patients
Nutritional deficiencies particularly that of iron and zinc and decreased supply of amino acids to liver causes reduced production of albumin levels thus leading to hypoalbuminemia https://www.ncbi.nlm.nih.gov/books/NBK526080/
Nutritional status as determined by Subjective Global Assessment -Dialysis Malnutrition Score is a useful and reliable index for identifying patients at risk for malnutrition and it correlates well with anthropometric and biochemical assessment .May be integrated in regular assessment of malnutrition in patients on maintenance hemodialysis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3224408/
Differences in diagnosis of 45 year old female and 58 year old man
As per the clinical findings of the patient of 45 year old
- Albuminuria
- decreased urine output
- Abnormal renal biopsy
- on USG - loss of CMD and increased echogenicity
- Hence could be diagnosed as Ckd due to diabetic nephropathy
- Increased bun/serum creatinine >20:1 which may indicate aki
- Low urinary output
- Flank pain
- On USG - there's no increase in echogenicity and other abnormality is not detected and left kidney size reduced
- Hence could be diagnosed as AKI
Differences in management:
45 year old patient :
- Potchlor was given to correct hypokalemia
- shelcal for hypocalcemia
- Lasix to correct fluid overload
- anti diabetic and anti hypertensive agents are given
- further investigations are done to improve the patient condition
- Piptaz - an antibiotic
- Amlong tablet - for treatment of hypertension
- Lasix to combat fluid overload
- Pantop - an antacid
- HAI - to reduce blood sugar levels
Differences in outcomes
in AKI :
- Mortality (26%)
- Renal recovery (68%)
- https://jasn.asnjournals.org/content/18/4/1292
In CKD :
- Progression of ckd
- mortality risks vary among various individuals
- https://www.karger.com/Article/FullText/254381
Would you agree with provisional diagnosis of 58 year male patient as per the online case report?
Yes I would agree with the provisional diagnosis that is AKI since the patient has bun / cretainine ratios increased >20:1 and he complained of burning micturition, hyponatremia (mild)
References :
1.Dr.Alekya Reddy mam's blog
2. Dr.Bhavya mam's blog
3.Harrison's book of medicine
4.all the links shared at their respective texts
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